We designed the study to explore the feasibility of using the T-MoCA test over the telephone to screen for cognitive impairment in the perioperative setting. This design involved determining whether clinicians from different specialties could quickly train to administer the test, if the time to conduct the test is reasonable, and if the test is acceptable for patients to complete before and after surgery. We demonstrate that T-MoCA test is easy to perform for clinicians and acceptable for patients in the perioperative period by showing high completion rates of both assessments and the ease of use by clinicians new to cognitive assessments. We have found that patients in our study (all age ≥ 70 years) can complete the test in less than 5 min while the overall encounter, including questions on medications, function, and anxiety screen, was completed in a median time of 8–10 min. In addition, we showed a high completion rate of the postoperative assessment (92.5%).
Previous studies have shown the importance of preoperative cognitive screening to evaluate cognitive impairment, which allows for mitigating postoperative complications such as delirium and postoperative cognitive decline (POCD) (Culley et al. 2017; Susano et al. 2020). These studies and others have led to a vast acceptance of the importance of cognitive screening in the preoperative period (Arias et al. 2020; Mahanna-Gabrielli et al. 2019; Cooper et al. 2020), though implementation remains challenging and limited (Rubin and Peden 2020). In addition, The Commonwealth of Massachusetts enacted a new law mandating all hospitals to implement an operational plan for early recognition and management of patients with dementia or delirium in acute care settings (Massachusetts-Health-Hospital-Association-Guidance-for-Developing-an-Operational-Plan-to-Address-Diagnosis.pdf 2021).
Our findings agree with the previously reported feasibility and reliability of administering a brief cognitive test over the phone. On the other hand, there are many other tools available for telephone-based cognitive assessments (Carlew et al. 2020), which are helpful not only in times of the pandemic for the safety of our patients and staff but for patients in remote areas as well, especially when coming to the hospital becomes more challenging. Available screening tests include Telephone Interview for Cognitive Status (TICS), animal fluency test, 8 Item Screener (8-IS), 6- Item Cognitive test (6-CIT), and others (Lines et al. 2003; Lipton et al. 2003). TICS was one of the earliest cognitive screening tests for dementia developed for administration via telephone. The TICS demonstrated a 94% sensitivity and 100% specificity for cognitive impairment and was also highly correlated with the Mini-Mental State Examination (MMSE) (Desmond et al. 1994). TICS does well in distinguishing dementia from normal cognition but is less sensitive at detecting mild cognitive impairment (MCI). One advantage of the T-MoCA test is that it correlates to the full MoCA test, which is more sensitive to detection of MCI than the MMSE (Nasreddine et al. 2005) and was specifically shown to be more sensitive for MCI in stroke patients as compared to TICS (Cohen and Alexander 2017). Furthermore, it was also recently shown to be a sensitive screening tool for MCI in diverse community-dwelling populations, with a high correlation to a complete, in-person neuropsychological evaluation (Katz et al. 2021). Another advantage we noted is that while this test assesses multiple cognitive domains, it is quickly conducted over the telephone and does not require more advanced technology such as video or other applications. Phone-based cognitive assessment is critical in the older population since many do not access to more advanced technologies. A recent study showed that up to 40% of American older adults are not ready for telemedicine video-based visits (Lam et al. 2020). On the other hand, many have access to telephones, making these perioperative assessments acceptable and readily accessible, even in times of limited in-person visits.
The T-MoCA test was designed as a screening tool for cognitive impairment. It should be used to trigger further in-depth cognitive evaluation, not serve solely as a diagnostic tool for either MCI, dementia, or POCD. In medical centers that have accessible geriatric services, using this test for cognitive screening and further seeking geriatrics expertise can assure better utilization of resources effectively for patients and clinicians. While recognizing the limited access to geriatrics clinicians in many hospitals and preoperative clinics, using this cognitive screening tool can help implement pathways for high-risk older adults with suspected cognitive impairment in the postoperative period (Bryant et al. 2019). Our future research will focus on the association of specific preoperative cognitive assessment to postoperative outcomes and implementation pathways to mitigate these risks in older adults who are candidates for major surgery.
Our study adds new information to the limited work on using this screening tool preoperatively. The single study involving the use of this tool preoperatively did not use an investigator who actually had obtained certification in using the tool, as noted in their methods section (Yu et al. 2021). Certification involves learning modules as well as an exam and would obviously be essential to ensure appropriate use and validate results, so it is difficult to make any conclusion about the results of this study. The other two studies involve use postoperatively as well as use in a geriatric virtual clinic (O’Gara et al. 2020; Joughin et al. 2021). Our institution as well as a number of others are in the process of implementing geriatric surgery multidisciplinary care; however, the triage to which patients actually see a geriatrician and the limited geriatric resources do not make this a viable option for routine use.
Our study has several limitations. First, this is the experience of a single, academic medical center in a population of older adults with high education level, functional baseline and socio-demographic characteristics that may limit the generalization of our results to other populations. On the other hand, since we found it acceptable to both patients and clinicians, we assume this should not be a barrier for broad implementation in different, perhaps less selected, settings.
Second, patients aged 85 years and older were less represented in this cohort due to challenges in recruiting older adults to clinical research studies. We believe that once this screening tool is implemented as part of routine preoperative assessment and conducted during the scheduled appointment, these barriers will no longer exist.
Third, we did not include in this study other clinicians such as nurses, physician assistants, and nurse practitioners. However, we believe that once the appropriate training is completed and routine quality assurance measures are performed, this should not limit wide implementation in the preoperative setting.